John Smith, M.D., P.A.
12345 Maple Drive
AnyCity, Florida 33000
phone: 555-123-4567
fax: 555-123-4568

AUTHORIZATION

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I, ____________________________________________________ hereby authorize John Smith, M.D., PA to endorse my name on medical claims submitted to my insurance companies for services rendered by John Smith, M.D.

I also authorize John Smith, M.D., PA to endorse my name on any checks/drafts received from my insurance company for services rendered to me.

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Signature

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Date

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Witness